Lisbon Fire Department Standard Operating Guidelines and Policies

Laryngoscope with functioning batteries

Laryngoscope blade of appropriate size for the patient with functioning light bulb

Magill forceps of appropriate size for the patient (Adult and pediatric size available)

Suction machine and catheters

Bag-Valve-Mask device with oxygen reservoir

Oxygen source with connecting tubing

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Assemble the laryngoscope and blade, checking the battery and the security of the light bulb in the blade.
   
3. 
   Position self at the top of the head of the patient.
   
4. 
   Place the patient’s head in a slightly extended (“sniffing”) position if no cervical injury is suspected. For patients with potential for cervical injury, in-line stabilization with the head in neutral position must be maintained by another individual.
   
5. 
   Holding the laryngoscope in the left hand, insert the blade into the right side of the patient’s mouth and move it gently toward the left, moving the tongue to the left and out of the way.
   
6. 
   Place the tip of the curved blade in the vallecula and the tip of the straight blade over the epiglottis.
   
7. 
   Lift up and anterior with the laryngoscope and blade to expose the posterior pharynx and the epiglottis without prying on teeth or gums.
   
8. 
   Visualize the vocal cords. Avoid any leverage on the laryngoscope blade or the teeth.
   
9. 
   Suction as necessary. (see guideline # 2002)
   
10. 
    Locate the foreign body.
    
11. 
    Holding the Magill forceps in the right hand, insert the tip into the patient’s mouth, grasp and remove the obstruction.
    
12. 
    Visualize the airway for further obstruction before removing laryngoscope blade.
    

13. 
    Ventilate the patient for 5-6 breaths with supplemental oxygen.
    
14. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Provides rapid removal of visualized object
  
• 
  Avoids potential trauma of abdominal thrusts
  

• 
  Requires specialized equipment and training
  
• 
  Must be able to visualize the object (must be superior to the vocal cords)
  

• 
  Oral or pharyngeal trauma
  

• 
  Foreign body is below the level of the vocal cords
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To maintain a patent airway by holding the tongue anteriorly off the posterior pharynx in unresponsive patients without a gag reflex.

Oral airway of size appropriate for patient

Size selection includes 40-100 mm

Tongue blade

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Select appropriate sized airway by measuring from the earlobe to the ipsilateral (same side) corner of the patient’s mouth or angle of the jaw.
   
3. 
   Open the patient’s mouth using the cross-finger technique. (Place the thumb on the lower teeth and the index finger on the upper teeth. Push the lower jaw down while pushing up on the upper jaw).
   
4. 
   Insert the airway with the tip pointing toward the roof of the patient’s mouth (for an adult); Follow normal curvature of mouth/pharynx for pediatric patients.
   

5. 
   Advance airway posteriorly, taking care not to push the tongue back or scrape the roof of the mouth until the tip reaches the soft palette.
   
6. 
   Rotate the airway 180º into position with the flange resting against the patient’s lips or teeth.
   
7. 
   Do NOT tape the airway in place.
   
8. 
   Suction patient as necessary to remove secretions. (see guideline # 2002)
   
9. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

• 
  Maintains patent airway by holding the tongue anteriorly off the posterior pharynx
  
• 
  Easy to use with minimal training necessary
  
• 
  Prevents the patient from biting down on objects in the mouth (e.g. endotracheal tube).
  

• 
  Does not prevent aspiration
  
• 
  Position may stimulate the gag reflex.
  
• 
  Cannot be used in the awake patient.
  

• 
  Oral trauma during insertion
  
• 
  Vomiting with possible aspiration as the level of consciousness increases.
  

• 
  Any individual with a gag reflex
  

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To maintain a patient airway by holding the tongue anteriorly off the posterior pharynx in a patient with a decreased level of consciousness

Nasopharyngeal airway of appropriate size for the patient

Size selections include sizes 12 through 34 (French).

Water soluble lubricant

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Select airway slightly smaller in diameter than the patient’s nostril, equal in length to the distance from the nostril to ipsilateral (same side) earlobe or angle of the jaw.
   
3. 
   Lubricate exterior of airway with water soluble lubricant.
   
4. 
   Insert airway into nares with bevel facing the nasal septum.
   
5. 
   Direct airway straight back along the floor of the nasal passage until the flange end touches the external nares.
   
6. 
   Suction as necessary to clear secretions. (see guideline # 2002)
   
7. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

• 
  Better tolerated than rigid oral airways
  
• 
  Less likely to stimulate gag reflex as patient regains consciousness
  
• 
  Can be inserted without having to open mouth.
  

• 
  Does not prevent aspiration
  

• 
  Insertion may cause epistaxis
  
• 
  Pharyngeal stimulation may cause gagging or vomiting.
  

• 
  Should not be inserted in patients with suspected basilar skull fractures or severe facial trauma.
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX *	XX	XX	XX

To prevent regurgitation of stomach contents into the airway

To facilitate ventilation of the lungs with a bag-valve device

To provide a more secure airway when endotracheal intubation is not feasible

Cardiopulmonary arrest

Respiratory arrest in the patient without a gag reflex

Unresponsive patient with inadequate respirations without a gag reflex

Combi-tube airway

140 cc syringe

20 cc syringe

Water soluble lubricant

Suction machine and catheters

Bag-valve device with oxygen reservoir

Oxygen source with connecting tubing

Stethoscope

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   For patients with a pulse, assure the patient is adequately pre-oxygenated while preparing equipment (~ 6 breaths with BVM). For patient with no pulse, follow AHA CPR guidelines and place Combi-tube while minimizing interruption of chest compressions. (pre-oxygenation is not needed.)
   
3. 
   Attach syringe and inflate the cuffs of the tube with air, check for leaks in the cuff, deflate.
   
4. 
   Remove dentures if possible.
   
5. 
   Lubricate the exterior of the Combi-tube with water-soluble lubricant.
   
6. 
   With the patient’s head in neutral position, place left thumb inside the patient’s mouth between the teeth and the cheek, fingers under the mandible and protract the patient’s lower jaw. Consider the necessity of c-spine stabilization during insertion.
   
7. 
   Gently insert the tube into the patient’s mouth, advancing the tube to follow the curvature of the posterior pharynx until the printed ring is aligned with the teeth. Do not use force. If the airway does not slide in easily, withdraw and attempt again to insert.
   
8. 
   Inflate pilot tube #1 (blue) with 100 cc of air using the 140 cc syringe. Assess for leaks, add 5-10 cc of additional air if leaking around cuff
   
9. 
   Inflate pilot tube #2 (white) with 15 cc of air.
   
10. 
    Attach bag-valve device to #1 (blue) tube and ventilate.
    
11. 
    Assess respiratory effect (breath sounds, epigastric sounds, chest rise, color improvement, etc.).
    

Combi-tube, cont.

12. 
    If chest rise and breath sounds indicate placement of the tube is in the esophagus, continue ventilation through blue tube. If breath sounds are absent, attach bag valve device to the #2 (white) port and ventilate.
    
13. 
    Assess respiratory effect (breath sounds, chest rise, color improvement, etc.).
    
14. 
    If chest rise and breath sounds indicate placement of the tube in the trachea, continue ventilation through the white port.
    
15. 
    If position is uncertain, deflate both cuffs, withdraw ½ inch, re-inflate both cuffs and reevaluate.
    
16. 
    If unable to ventilate adequately through either port, remove the Combitube and reattempt placement (steps 6-14). No more than 30 seconds should elapse for each attempt. If 3 attempts are unsuccessful, an alternate airway adjunct should be used. Re-oxygenate for 30 seconds between attempts for patient with pulse. For patients without a pulse, continue AHA-SPR between attempts.
    
17. 
    Once placement is successful in a patient with pulses, hyperventilate for 30 seconds and the continue ventilation of the patient according to AHA guidelines. For the patient without a pulse, skip the hyperventilation step.
    
18. 
    Reassess tube placement and ventilatory status frequently.
    
19. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

1. 
   Assure suction is immediately available.
   
2. 
   Turn patient on side unless contraindicated (e.g. C-spine)
   
3. 
   Deflate both cuffs and gently but quickly remove.
   
4. 
   Anticipate regurgitation and suction as necessary.
   
5. 
   Reassess respiratory status.
   
6. 
   Provide supplemental oxygen.
   

• 
  Ease of insertion, cannot be improperly placed
  
• 
  Requires minimal skill and training
  
• 
  Requires minimal spinal manipulation
  
• 
  Provides for ease of suctioning
  

• 
  Can only be used if unconscious without gag reflex
  
• 
  Not tolerated by semiconscious or awake individual
  
• 
  Must identify where tube is located (esophagus or trachea)
  
• 
  May need to be removed before endotracheal intubation is possible
  

• 
  Possible esophageal damage from inflation of the cuff
  

• 
  Individuals less than 5 feet in height or taller than 7 feet**
  
• 
  Known esophageal disease or trauma
  
• 
  Known foreign body obstruction of larynx or trachea
  
• 
  Intact gag reflex
  
• 
  Caustic ingestion
  
• 
  Use with caution in patients with facial trauma, broken teeth/dentures
  

**Note: A small adult Combitube is available for individuals greater than 4 ft and less than 5 feet in height. Inflate the blue pilot tube with 85 cc of air and the white with 12 cc.

END
GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
		With added module	XX	XX